Cinotti A, Massari L, Traina G C, Mannella P
Istituto di Radiologia, Università degli Studi, Ferrara.
Radiol Med. 1996 Jan-Feb;91(1-2):28-32.
Thanks to its good long-term results, surgery is the method of choice to treat subcutaneous ruptures of the Achilles tendon. Reconstructed tendons present typical morphological and functional US patterns which depend partly on the kind of surgical reconstruction and partly on the time passed since surgery. The authors report the results of the clinical and US follow-up of a series of 62 surgical patients treated in 7 years for the subcutaneous rupture of the Achilles tendon. The patients were 55 men and 7 women, whose mean age was 36 years (range: 25-65 years). The left-hand side was affected in 38 patients and the right-hand side in 24 patients. All patients were operated on using an end-to-end suture and reinforcement plastic surgery pulling down a gastrocnemius tendon flap. To homogenize the results, all the US exams were performed by the same operator, in the presence of the orthopedic specialist and under the same conditions: both the involved and the contralateral Achilles tendons were studied, longitudinal and transverse scans were performed with the foot in max. plantar and dorsal flexion and, whenever possible, dynamic scans were also performed making the sural triceps contract against resistance. The following parameters were studied clinically: pain (which was absent in 39 patients, occasional in 11, after stress in 9 and on walking in 3 patients), skin scar trophism (which was eutrophic in 53.23% of patients, keloid in 27.42% and hypertrophic in 19.35% of patients), ankle joint excursion (plantar flexion was impaired in 32.3% and dorsal flexion in 36% of patients), walking on tiptoe (in all, 22.6% of patients complained of difficulties walking on tiptoe) and, finally, work activity resumption (which all patients achieved). US depicted the surgical tendons as much bigger than the contralateral ones (3-4 times on the average), which increase in volume lasted throughout the follow-up. In 75% of patients the echo structure of the surgical tendons was inhomogeneous, with scattered hypoechoic and hyperechoic areas. In the extant 25% of patients, nearly all of them followed-up for over 6 years, US depicted a clear-cut hyperechoic area whose size and echo structure were similar to the healthy tendons'. Our results strongly suggest that tenorrhaphy and flap plastic surgery be used to repair subcutaneous ruptures of the Achilles tendon. US proved to be the most reliable and feasible method also in the follow-up. The US images of the patients submitted to surgery more than 6 years earlier revealed fibrillate reorganization patterns and tendon restructuring. These processes involve both ends of the sutured tendon and not the reinforcement flap, which further confirms the exclusively mechanical, and not biological, function of the latter.
由于手术具有良好的长期效果，因此它是治疗跟腱皮下断裂的首选方法。重建后的肌腱呈现出典型的超声形态和功能模式，这部分取决于手术重建的方式，部分取决于手术后经过的时间。作者报告了一系列62例在7年中接受手术治疗跟腱皮下断裂患者的临床和超声随访结果。患者中男性55例，女性7例，平均年龄36岁（范围：25 - 65岁）。左侧受累38例，右侧受累24例。所有患者均采用端端缝合及下拉腓肠肌腱瓣的加强整形手术进行治疗。为使结果具有可比性，所有超声检查均由同一名操作者在骨科专家在场且相同条件下进行：对患侧和对侧跟腱都进行研究，在足部最大跖屈和背屈时进行纵向和横向扫描，并且只要有可能，还进行动态扫描，使小腿三头肌对抗阻力收缩。临床研究了以下参数：疼痛（39例患者无疼痛，11例偶尔疼痛，9例用力后疼痛，3例行走时疼痛）、皮肤瘢痕营养状况（53.23%的患者瘢痕营养良好，27.42%为瘢痕疙瘩，19.35%为增生性瘢痕）、踝关节活动度（32.3%的患者跖屈受限，36%的患者背屈受限）、踮脚尖行走（总共22.6%的患者抱怨踮脚尖行走困难），最后是工作活动恢复情况（所有患者均已恢复）。超声显示手术修复后的肌腱比另一侧肌腱大得多（平均大3 - 4倍），并且在整个随访过程中体积持续增大。75%的患者手术肌腱的回声结构不均匀，有散在的低回声和高回声区域。在其余25%的患者中，几乎所有患者的随访时间超过6年，超声显示出一个清晰的高回声区域，其大小和回声结构与健康肌腱相似。我们的结果强烈表明应采用肌腱缝合术和瓣整形手术来修复跟腱皮下断裂。超声在随访中也被证明是最可靠和可行的方法。对6年多前接受手术患者的超声图像显示出纤维状重组模式和肌腱重塑。这些过程涉及缝合肌腱的两端，而不涉及加强瓣，这进一步证实了后者仅具有机械功能而非生物学功能。
